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CLINICAL MANAGEMENT GUIDELINES
Trauma (blunt)
Aetiology
Blow to the eye: accidental (e.g. RTA, industrial, domestic, sports) or
non-accidental (e.g. fist)
Also known as ocular contusion
Predisposing factors Usually unexpected but may be vocational (e.g. boxing)
Symptoms
Pain varies from mild to severe
Epiphora
Visual loss (variable)
Photophobia
Signs
Mild cases (usually with good corrected vision)
• eyelid swelling (oedema), ecchymosis (bruising)
• conjunctival chemosis, subconjunctival haemorrhage
• corneal abrasion
Severe cases (usually with some loss of visual function)
• infraorbital nerve anaesthesia (lower lid, cheek, side of nose,
upper lip, teeth) may indicate orbital floor fracture
• disturbance of ocular motility: restriction or diplopia due to tissue
swelling or muscle tethering by orbital (‘blow-out’) fracture
• enophthalmos (sunken eye) may also indicate orbital fracture
• nasal bleeding (direct trauma, or could indicate skull fracture)
• corneal oedema or laceration
• AC: hyphaema (blood in aqueous), uveitis, flare and cells
• traumatic mydriasis
• iridodialysis (tearing of iris from its attachment to ciliary body)
• lens: evidence of subluxation, cataract, capsule damage
• IOP may be increased secondary to uveitis, or reduced because
of scleral perforation (rupture of globe)
• vitreous haemorrhage
• commotio retinae, retinal detachment or dialysis
• traumatic macular hole
• globe rupture (full thickness wound of eye wall)
• relative afferent pupillary defect (indicates traumatic optic
neuropathy)
Differential diagnosis Other causes of acute red eye
Pre-septal cellulitis
Management by Optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer
the patient elsewhere
Non pharmacological
Careful history required, including mechanism and time of injury
Lid oedema: cold compress to ease swelling
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Systemic analgesia e.g. paracetamol, aspirin
If there is significant tissue swelling: non-steroidal anti-inflammatory drug
(e.g. ibuprofen)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
In cases of corneal abrasion consider topical antibiotic
(GRADE*: Level of evidence=low, Strength of recommendation=weak)
Management Category
Management depends on severity of injury
Mild cases:
B2: alleviation or palliation; referral unnecessary
Severe cases:
Trauma (blunt)
Version 11, Page 1 of 2
Date of search 20.07.15; Date of revision 18.12.15; Date of publication 05.02.16; Date for review 19.07.17
© College of Optometrists
CLINICAL MANAGEMENT GUIDELINES
Trauma (blunt)
A2: first aid measures and emergency (same day) referral to A&E
Possible management by Ophthalmologist
Assessment and investigation including imaging (e.g. X-ray, CT, MRI)
Treatment of globe rupture where present
May require hospital admission
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and
Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm)
Sources of evidence
Alteveer J, Lahmann B. An evidence-based approach to traumatic ocular
emergencies. Emergency Medicine Practice 2010;12(5):1-21
Kuhn F, Morris R, Witherspoon CD, Mester V. The Birmingham Eye
Trauma Terminology system (BETT). J Fr Ophtalmol. 2004;27(2):206-10
Lecuona K. Assessing and managing eye injuries. Community Eye
Health. 2005;18(55):101-4
LAY SUMMARY
The eye is well protected by the bony structures of the face that surround it (brow, cheek, nose) but
it is sometimes injured by a direct blow, which is usually accidental but is sometimes the result of
an assault. In mild cases this often results in bruising and swelling of the tissues around the eye (a
‘black eye’) which resolves fully in time leaving no after-effects; painkillers may be the only
treatment needed. In more severe cases one or more of the bones of the orbit (the bony cavity in
which the eyeball sits) may be fractured and this may cause the eye or one of the muscles that
moves it to be displaced. The blow to the eye may also damage the structures inside the eye and
may cause internal bleeding. Such cases need to be referred as emergencies to the
ophthalmologist.
Trauma (blunt)
Version 11, Page 2 of 2
Date of search 20.07.15; Date of revision 18.12.15; Date of publication 05.02.16; Date for review 19.07.17
© College of Optometrists